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Contact Lens Re-order
Please complete this form below to request a re-order on your contact lenses. Our staff will verify your contact lens prescription with your medical record. If you request direct shipping our staff will contact you to arrange payment, otherwise you may pay for your order on pickup.
Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
used for identification, and verification of prescription
Phone
*
###
-
###
-
####
Email
*
Order me a
*
One year supply
6 month supply
3 month supply
Please note; 3 month supplies are no longer available on most contact lens orders due to recent changes in packaging by several manufacturers.
Shipping
*
To Bancroft Eye Care - I'll pick them up
To the address provided below
Address - required for direct shipping option
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Direct shipping is only available within Canada.
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